A federal watchdog says the Veterans Health Administration (VHA) needs to tighten up its credentialing after discovering multiple instances where veterans were being seen by providers who were disqualified from delivering patient care, according to a new report.
The Government Accountability Office (GAO) said in its review of 57 providers (PDF), it found adverse-action information from the National Practitioner Data Bank (NPDB) was either overlooked or was completely missed by some facilities.
The report was developed for the House Committee on Veterans’ Affairs Subcommittee on Oversight and Investigations.
"VHA facilities did not consistently adhere to policies regarding providers with adverse actions," the report said.
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In some cases, GAO found officials were not aware of VHA employment policies.
For example, in at least five facilities the GAO found officials involved in verifying providers’ credentials and hiring them were unaware of the policy regarding hiring a provider whose license has been revoked or surrendered for professional misconduct or incompetence, or for providing substandard care would be ineligible for employment.
In one case, the VHA hired a physician who had surrendered his physical therapy license for not completing physical therapy continuing education. But the VHA determined that there were no concerns about the provider’s ability to perform as a physician.
In another case, VHA officials told GAO they inadvertently overlooked a disqualifying adverse action and hired a nurse whose license had been revoked for patient neglect. That nurse resigned in May 2017.
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The GAO made several recommendations, including that the VHA ensure that facility officials responsible for credentialing and hiring receive periodic mandatory training. It also recommended those officials periodically review providers who have an adverse action reported in NPDB.
The VHA agreed with the GAO’s recommendations.